Related Information

Patient Harm Prevention

Patient harm
(hospital-acquired conditions) is unintended physical injury resulting from or
contributed to by medical care, including the absence of indicated medical
treatment that requires additional monitoring, treatment, or hospitalization.

HAP Works with Pennsylvania Hospitals to Reduce Patient Harm

HAP, through its Hospital Improvement Innovation Network (HIIN) is helping Pennsylvania hospitals and health systems with analyzing the cause of harm, identifying prevention strategies, and ensuring that those strategies become part of a culture of safe, patient-centered care.

Current patient harm prevention initiatives include:

Adverse Drug Event Prevention—Adverse drug events can include medication errors, such as too much or too little medicine, or an unexpected reaction, such as an allergic reaction. Medication errors can result in patient harm, including death.

Venous Thromboembolism Prevention—Venous thromboembolism (VTE), is a condition in which unwanted blood clots form in the body. These blood clots can sometimes lead to serious health conditions or even death. Patients admitted to the hospital are at increased risk for this condition, especially if they have surgery or stay in the hospital for a long time.

Falls Prevention—Patient falls with injury represent the most frequently reported serious patient event by hospitals in Pennsylvania. However, falls represent a patient safety challenge for all health care facilities.

Pressure Ulcer Prevention—Hospitals have long been challenged to protect bed-ridden patients from getting pressure injuries (also known as bedsores). Pressure injuries constitute skin breakdown that can be painful, may impact a patient’s quality of life, and may slow recuperation from other illnesses.

Severe Sepsis and Septic Shock—Sepsis (also known as blood poisoning) is an often deadly disease that sometimes occurs when the body is overwhelmed by infection. Sepsis can be difficult to diagnose, because it often happens quickly, and can be confused with other conditions.

Antimicrobial Stewardship, Clostridium difficile, Multi-drug Resistant Organisms—Complications can occur when patients receive unnecessary antimicrobial medications, including antibiotics. Antimicrobial stewardship refers to a coordinated effort designed to promote appropriate use of these medications. Clostridium difficile infection (CDI) refers to a serious infection which results in the disruption of normal healthy bacteria in the colon, often from antibiotics. Multi-drug resistant organisms (MDROs) are bacteria and other organisms that have developed resistance to multiple antimicrobial drugs. Widespread use of antibiotics has resulted in many MDRO’s.

Readmissions—Frequent and unnecessary hospital readmissions within 30 days of a hospital stay are costly, potentially harmful, and often avoidable.

Diagnostic Error in the Emergency Department—Imaging procedures, such as x-rays, magnetic resonance imaging (MRI) and computed tomography (CT) scans represents an understudied area of patient safety with many opportunities for improvement.

Computed Tomography (CT) Safety—While CT can be a lifesaving tool for diagnosing injuries and illness, reducing undue exposure to radiation is important in that too much radiation exposure can be detrimental to human health.

Incredible work is being done across the state as Pennsylvania hospitals step up to improve health care. This week, we’re sharing an award-winning initiative from UPMC St. Margaret to improve the medication history discrepancy rates in patient medical records.

News Release: Pennsylvania’s hospitals continue to make strides in improving the quality and outcomes of the care they deliver to patients across the commonwealth, according to a report released today by the Pennsylvania Health Care Cost Containment Council (PHC4).